The magic of xylitol

Xylitol is a magic bullet for dental health. It affects the dental decay process in the most unusual way. It doesn't grow enamel. It doesn't make teeth more resistant to acid challenges. It really does not directly do anything to, or for, the teeth.

by Shirley Gutkowski

Xylitol is a magic bullet for dental health. It affects the dental decay process in the most unusual way. It doesn't grow enamel. It doesn't make teeth more resistant to acid challenges. It really does not directly do anything to, or for, the teeth. Instead, xylitol works on the bacteria that cause dental decay, mainly Mutans streptococci (MS).

Let's take a little trip along the chain of events that initiate a carious lesion. Bacteria, mainly MS, consume the sugars lifted through the lips of their most obliging host. Long and short chain carbons and simple and complex carbohydrates are the ambrosia that makes bacteria happy to be germs. They devour them ... yummy. The bacteria get fat, healthy, and multiply. Their abbreviated digestive process changes the carbon chains into an acid that is excreted from the cell walls, caressing them with the pH only a strep mutans could love. The acid environment is an ideal atmosphere for the germs that cause decay.

The acid dissolves the calcium/phosphorous matrix that makes up enamel, breaking the molecular bond between them, like a vixen coming between complacent lovers.

If there's fluoride floating by, the calcium and phosphorus bind together with a molecule of fluoride and form another unit, stronger than the other. It's more difficult to break this match made in chemistry. If there's no fluoride nearby, the essential elements of enamel float free, leaving a microscopic void in the tooth. As more bonds break free, the void becomes bigger, the bacteria take up residence and soon the mechanical actions of mastication and mindless tooth brushing cannot remove the biofilm growing there.

Traditionally, we've put fluoride on the teeth, hoping for the chemical conversion and in the case of APF, helping it along by supplying acid to force the breakup, and force the makeup. This is all done in the name of fighting decay. This disregards the bacterial nature of the disease and ignores it as an infection.

A decade or more ago, chlorhexidine came into the picture. It was proven all around the world to help fight gingivitis by killing bacteria — not just the periodontal pathogens but all of them in the oral cavity. Little mention was made of its use for decay. Today, it's useful as part of the protocol for remineralization therapy. But the benefits aren't as long lasting as xylitol.1,2

Xylitol decreases the infection from the onset — shifting the ecology of the mouth to one that favors bacteria that don't cause decay. A good canopy above the shade-loving plants provides a healthy living environment on the rain forest floor. A good amount of xylitol provides a healthy environment for an ecosystem that is less harmful to the dentition. Imagine a food that MS loves. Imagine that when they dine on this marvelous food, they cannot metabolize it to an acid. The food doesn't metabolize at all; it is excreted whole, skipping the part where the bacteria become nourished by it. More importantly, skipping the part where the pH drops.

Without the acidic excrement to wallow in, the bacteria's habitat becomes intolerable and they don't proliferate. They become less and less a demographically viable constituent of the biofilm. Bacteria less harmful to the enamel start to proliferate. Although the bacteria count per milliliter is the same, the veracity of the bunch is very much less. The ecology has been shifted toward disease for so long, some consider it normal and have trepidations about messing with the oral flora.

Some would call it an artificial sweetener, although xylitol is a naturally occurring sugar alternative. It is manufactured in small amounts by our own bodies. It is manufactured on a large scale from the wood of hardwood trees.

Forests are not cleared in order to collect enough wood to make it. The wood comes from managed forests; it is broken down, processed and purified to produce pure xylitol. The wood not used for xylitol production is used by other industries. It's almost like recycling.

The time to start ingesting xylitol for maximum benefit is during the year directly before eruption of the tooth, for instance age five.3 The principal beneficiaries of xylitol are children whose parents or caregivers have a decay problem. Since the bacteria most associated with early stages of decay are transmitted from caregiver to child (most often from the mother), decreasing the bacterial count in the caregiver can be advantageous for the child. For children to benefit substantially from xylitol, the primary caregiver should chew xylitol gum before the baby's teeth erupt for approximately 18 months. No kidding.4,5,6

Up until a few years ago, xylitol as an ingredient was nearly impossible to find. Today, a magnifying glass is all you need to find it on the back of toothpaste, mouthwash, candies, and gum packages all around the supermarket, drug store, or gas station. Health food stores stock granulated xylitol. In gum, look for xylitol as one of the first three ingredients to be an effective amount.

Check to see how much of the product constitutes a serving size. For instance, one stick of gum is usually considered one serving; however, gum pellets are usually two to a serving. Throughout the day, four servings is the minimum requirement to achieve dental benefits and avoid GI upset that can occur at higher dosages. Four to 12 grams a day is the amount to target if granulated xylitol is the preferred method.

Another magical thing about xylitol is the benefit to children suffering from otitis media. The same family of bacteria, Streptococcus pneumoniae, causes this most distressing disease common in small children. The anatomy of a small child's head makes for a lovely superhighway from the oral cavity to the middle ear via the Eustachian tube. Decreasing the amount of available bacteria to set up the infection is a holistic way to treat the disease. Current thought on otitis media treatment is to allow it to clear up on its own in due time. Yeah, right. It's a painful condition and parents can't sleep when the baby's in pain. More studies should follow up on this unique treatment. Everyone is concerned about the overuse of antibiotics, but to allow a child to suffer, or take only pain medications when xylitol is around is very short-sighted.7,8

Sugar alcohols don't promote pancreatic hormone excretion, making it a safe alternative for diabetic patients. The body doesn't react to sugar alcohols in the same way that it reacts to sucrose or glucose. None of the sugar alcohols affect the pancreas, but none of the other sugar alcohols, like manitol or sorbitol, have as beneficial an effect on dentition as xylitol.

If you have room in your brain for another benefit, xylitol has also been found effective as a deterrent to yeast infections. Often, yeast infections are treated with Nystatin, an antifungal agent that is swished and swallowed. It's very effective against the yeast and very effective at promoting decay. A new version was developed without glucose because of the effect on diabetics. Xylitol decreases the ability of the Candida to adhere to the mucosa, making an infection nearly impossible.9,10

There are a few drawbacks to using xylitol. One is the GI effect of taking too much or taking too much too soon. This adverse effect is easily overcome by ramping up the amount ingested every day. The other is called xylitol-resistant MS. The bacteria that become accustomed to xylitol and still live become docile, if germs can be docile. They do not produce as much of the mucopolysaccharide as their counterparts do. This makes the bacteria less adhesive, therefore, virtually harmless to the dentition and allows them to be easily removed from any oral surface during mastication or oral care ... a kink in their microevolution.

See? Magical.

Partial, alphabetical list of products containing clinically proven levels of xylitol

• Koolerz gum
• Laclede products
• Rembrandt products
• Smint mints
• Squigle Toothpaste (contains the most xylitol of any toothpaste)
• Starbucks mints
• TheraGum (office distribution only — Omnii Pharmaceuticals)
• (offers xylitol cheesecake and pet food)

Shirley Gutkowski, RDH, BSDH, has been a practicing dental hygienist since 1986. She is a popular speaker and award-winning author. Gutkowski and Amy Nieves, RDH, are the co-authors of "The Purple Guide: Developing Your Dental Hygiene Career," a handbook for graduates from dental hygiene school. Gutkowski can be contacted at

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9. Pizzo G, Giuliana G, Milici ME, Giangreco R. "Effect of dietary carbohydrates on the in vitro epithelial adhesion of Candida albicans, Candida tropicalis, and Candida krusei," New Microbiology 2000 Jan; 23(1)
10. Samaranayke LP, MacFarlane TW. "The effect of dietary carbohydrates on the in vitro adhesion of Candida albicans to epithelial cells," Journal of Medical Microbiology 1982 Nov; 15:4

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